Dermatological perspectives on pressure alopecias: A call for awareness
Authors: Eduardo Corona-Rodarte, Luis Enrique Cano-Aguilar, Luisa Fernanda Baldassarri-Ortego, Antonella Tosti, Daniel Asz-Sigall
Journal: Journal of the American Academy of Dermatology (2023)

We were delighted to read the insightful commentary published by Novice et al1Novice M, Shapiro J, Lo Sicco KI. Response to Corona-Rodarte et al.'s "Pressure alopecias: a review." J Am Acad Dermatol. Published online August 8, 2023;S0190-9622(23)02648-8. https://doi.org/10.1016/j.jaad.2023.08.062Google Scholar regarding pressure alopecias (PA). Our article categorized PA into type 1 and type 2 based on sustained external pressure and direct pressure, which can result from arterial vessels and capillaries' compression due to infiltration and/or extravasation, respectively. This classification offers valuable insights into this dermatological concern, emphasizing that although type 2 PA is predominantly caused by a cosmetic injection, it is not exclusive to it. Novice et al1Novice M, Shapiro J, Lo Sicco KI. Response to Corona-Rodarte et al.'s "Pressure alopecias: a review." J Am Acad Dermatol. Published online August 8, 2023;S0190-9622(23)02648-8. https://doi.org/10.1016/j.jaad.2023.08.062Google Scholar introduce 3 additional cosmetic procedures associated with type 2 PA, namely, thread lifts (facial suspension sutures), temporal lifting with dermal fillers, and cervicofacial rhytidectomy (facelift). This inclusion enriches our understanding of the potential causes and risk factors associated with alopecia in the context of cosmetic procedures. The case described involving thread lifts highlights the significance of considering both pressure and tension mechanisms as potential synergic force that can cause alopecia.2Paik S.H. Kim H.T. Chang S.E. Severe bitemporal alopecia as a complication of the thread lift procedure.Dermatol Surg. 2019; 45: 983-986Crossref PubMed Scopus (7) Google Scholar Although pressure refers to a calculable force per unit area pushing on tissue, tension-induced ischemia resulting from the anchoring process can also affect hair follicle units.3Barrera-Ochoa C.A. Alonso-León M.T. Arenas R. Vega-Memjie M.E. Asz-Sigall D. Secondary alopecia induced by aesthetic procedures: an unrecognized potential complication.Australas J Dermatol. 2023; 64: 322-329Crossref PubMed Scopus (3) Google Scholar The varying etiologies of alopecia following thread lifts underscore the need for further research to fully comprehend the underlying causes. Additionally, the report by Landau et al4Landau M. Lopez-Gehrke I. Villarica-Hayano W. Suwanchinda A. Galadari H. Nonscarring alopecia after temporal lifting technique with dermal fillers.JAAD Case Rep. 2023; 37: 30-34Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar on alopecia following dermal filler injections in the posterior temple lifting technique is illuminating; it is remarkable that in most patients, 1 mL of filler per site was injected. The authors' hypothesis regarding compression of the superficial temporal artery and resulting hypoxia as a potential cause of alopecia highlights the complex interplay of factors in these cases. A retrospective study examining the use of topical minoxidil in patients undergoing cervicofacial rhytidectomy (facelift) reveals potential preventive measures.5Eremia S. Umar S.H. Li C.Y. Prevention of temporal alopecia following rhytidectomy: the prophylactic use of minoxidil. A study of 60 patients.Dermatol Surg. 2002; 28: 66-74PubMed Google Scholar The decrease in temporary alopecia rates observed with topical minoxidil application implies that addressing pressure-induced hypoxia could potentially enhance outcomes in both nonscarring and scarring alopecia cases linked to facelift procedures. As the frequency of cosmetic interventions keeps rising, it becomes increasingly plausible that cases of PA may become more prevalent. The diverse etiologies and risk factors associated with these cases warrant continued research to enhance our understanding and inform best practices in patient care. Thank you for the opportunity to comment on this important matter. We look forward to further researching and raising awareness in this field, ultimately benefiting both practitioners and patients. Dr Tosti is a consultant for DS Laboratories, Monat Global, Almirall, Thirty Madison, Eli Lilly, Bristol Myers Squibb, P&G, Pfizer, and Myovant. Drs Corona-Rodarte, Cano-Aguilar, Baldassarri-Ortego, and Asz-Sigall have no conflicts of interest to declare. Response to Corona-Rodarte et al.'s "Pressure alopecias: a review"Journal of the American Academy of DermatologyVol. 89Issue 6PreviewTo the Editor: We read with interest the article by Corona-Rodarte et al regarding pressure alopecias (PAs) secondary to sustained external pressure and cosmetic injections, which they referred to as type 1 PA and type 2 PA, respectively. We introduce 3 additional cosmetic procedures that have been associated with alopecia: thread lift (facial suspension suture), temporal lifting with dermal fillers, and cervicofacial rhytidectomy (facelift). We also want to consolidate recommendations for counseling and management of alopecias secondary to cosmetic injections and procedures. Full-Text PDF